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Wednesday, August 2, 2017

Proposed Changes to the Ratings of the Genitourinary System

--THE VA WITHDREW THESE PROPOSED CHANGES ON 3/5/19 DUE TO ERRORS WITHIN THE PROPOSED RATING REQUIREMENTS. THEY ARE INSTEAD CREATING NEW, CORRECTED PROPOSED CHANGES THAT WILL BE RELEASED FOR OUR REVIEW AT A FUTURE DATE.--

On July 28th, 2017, the VA finally published
a new section of proposed VASRD changes, this time to the ratings of the Genitourinary System. It has been almost a year since they published their last set of
proposed changes to the ratings of the Skin.

The rewrite of the VASRD began in 2014 with
the goal to be finished by the end of 2016. With significant delays, and many
more sections left to go, there is no longer any clear timeframe as to when
veterans can expect these changes to be finalized. So far, only the ratings for
Mental Disorders have officially been updated. Although six other sections
have been proposed so far, none of the proposed changes have yet been finalized
and implemented.

With each set of proposed changes, the VA
allows a period in which comments can be submitted. The VA then takes each
comment into consideration and makes any additional changes that are warranted
before publishing the final ruling.

We encourage you to submit any comments you
might have on these proposed changes to us either by commenting on this post or
by contacting us through our website. All comments must be received by
September 8th, 2017. We will then compile all of your comments into a single
report and submit it on your behalf to the VA, just as we did for the other
sections (see the Female Reproductive System Comments). This is a great
opportunity to really make a difference, so please let us know your thoughts.

The following are the VA’s proposed changes
to the ratings for the Genitourinary System. The changes are fairly extensive,
so I’ll walk through each, one at a time.

For each condition, the small, indented
parts are the codes as they are right now. Click on the links to be taken to
the discussion of that code on our site. After the current code, I’ll discuss
the proposed changes and the VA’s justification.

-Current- Code7542: A Neurogenic
Bladder occurs when a person loses control over urination because of
damage to the nerves or the brain. This condition is rated on the Urinary
Rating System.

-Proposed-Code 7542: A Neurogenic Bladder occurs
when a person loses control over urination because of damage to the nerves or
the brain. This condition is rated on either the Urinary Rating System or as a
Urinary Tract Infection, whichever gives the higher rating.

The only change to this code is allowing it
to be alternatively rated as a urinary tract infection. This is because
neurogenic bladders have a high rate of urinary tract infections, so if that is
the predominant disability and would offer a higher rating, that should be an
alternative rating option.

-NEW Proposed Code-Code
7545: Diverticulum of the bladder occurs when the wall of the bladder
weakens and a portion protrudes, creating a pouch. This causes urine to get
trapped in the pouch, leading to voiding dysfunction and/or infection. It can
be rated either on the Urinary Rating Systems or as a Urinary Tract Infection,
whichever is the main disability.

The VA proposes to add this new code to
cover diverticulum of the bladder. Currently, there aren’t any codes that truly
reflect the disability of this condition. Thus it needs its own code.

A 30% rating is given if the condition causes regular
infections that require hospitalization 3 or more times a year, or if
it requires serious continuous treatment.

A 10% rating is given if the condition requires
regular drug therapy, 1 or 2 hospitalizations a year, or if it requires serious
continuous treatment.

If any of these conditions that are rated as urinary
tract infections also cause renal problems, then only one or the
other can be rated. If the renal problems are more severe, then the condition
should be rated under the renal rating system.

-Proposed- The ratings:

A 30% rating is given if the condition causes regular infections that
require a stent or nephrostomy tube to be implanted for drainage, if the
condition requires hospitalization 3 or more times a year, or if
it requires serious continuous treatment.

A 10% rating is given if the condition requires suppressive drug therapy
for 6 months or more, or 1 or 2 hospitalizations a year.

A 0% rating is given if the condition is recurrent and requires
treatment of suppressive drug therapy for less than 6 months or antibiotic
therapy, and does not require hospitalizations.

If any condition rated as a urinary tract infection also causes renal
problems, then only one or the other can be rated unless they are diagnosably
separate with clearly separate symptoms. If the renal problems are more severe,
then the condition should be rated under the renal rating system.

The changes to the 30%
simply specify that the infection must require drainage by more than a catheter
in order to be rated at this level. Catheter drainage does not require surgery
and rarely requires significant hospitalization.

The changes to the 10%
more clearly define the required treatment. The VA argues that suppressive drug
therapy for at least 6 months suggests a significant chronic condition
appropriate for this rating level.

A 0% rating was added
to enforce that anything less than the requirements for the 10% should be given
a 0%.

-Current- Code 7525: Chronic
Epididymo-orchitis is pain in the epididymis. If the pain is caused by
tuberculosis, it is rated as nonpulmonary
tuberculosis.

-Proposed- Code 7525: The following chronic infections are all rated under this code: epididymitis
(infection/inflammation of the epididymis), prostatitis (infection/inflammation of the prostate gland, urethritis (infection/inflammation of
the urethra), and orchitis
(infection/inflammation of the testicles—one or both). If the condition is caused by tuberculosis, it
is rated as nonpulmonary tuberculosis.

-Current- Code 7527: Prostate Gland
conditions (any) are either rated as urinary tract infections or by the urinary
rating system, whichever better defines the symptoms of the condition.

-Proposed- Code 7527: Prostate Gland conditions (all except prostatitis) and bladder outlet obstruction are rated
under this code either as urinary tract infections or under the urinary rating
system, whichever better defines the symptoms of the condition.

The VA recognized that there were quite a
few infections that were not technically covered under the current codes, and
so decided to add them in order to avoid improper analogous ratings. Thus, now
code 7525 covers four conditions instead of just epididymitis. All of these
conditions should have been rated under this code anyway, since they cause
similar symptoms, but now it is official. No change in how they are rated.

For code 7527, they decided to move
prostatitis to 7525 because it is closer to the other infections covered by
that code. All other prostate conditions are still covered under this code. The
VA also decided to add bladder outlet obstruction because it is often caused by
a prostate condition and can produce similar symptoms. Thus, it needs the
option to be rated as a urinary tract infection as well.

-Current- A 100% rating is given if at
least one of the following is present:

– The condition requires regular dialysis.

– The body cannot perform any physical activity
because of persistent edema or because of albuminuria.

– A BUN of more than 80 mg/dL.

– A creatinine level of 9 mg/dL or more in the blood.

– A severely decreased functioning of the kidneys or
other organs due to kidney dysfunction.

An 80% rating is given if one
or more of the following is present:

– Persistent edema and albuminuria with a BUN
of 40 to 80 mg/dL.

– A creatinine level of 4 to 8 mg/dL in the blood.

– Overall poor health with symptoms like lethargy,
weakness, anorexia, weight loss, or the inability to exert much energy.

A 60% rating is given if one
or more of the following is present:

– Constant albuminuria with some edema.

– A definite decrease in kidney function.

– Hypertension with the average diastolic pressure
(the smaller number on the bottom in the blood pressure reading) of 120 or
more.

A 30% rating is given if one
or more of the following is present:

– Hypertension with the average diastolic pressure
(the smaller number on the bottom) of 100 or more, or with the average
systolic pressure (the larger number on top) of 160 or more.

– Albumin is present in the urine with either hyaline
and granular casts or red blood cells.

A 0% rating is given if:

– Hypertension with the average diastolic pressure of
less than 100, or with the average systolic pressure of less than 160.

– Albumin and casts are present in the urine with a
history of nephritis.

-Proposed- To qualify for the following
ratings, there must be a chronic kidney disease present.

A 100% rating is given if at least one of the
following is present:

– A GFR (glomerular filtration rate) less than 16mL/min

– The condition requires regular dialysis.

– Requires a kidney transplant (has not yet received one)

An 80% rating is given if the GFR is between 16
and 29 mL/min.

A 60% rating is given if the GFR is between 30
and 59 mL/min.

A 30% rating is given if the GFR is 60 mL/min
or more AND at least one of

the following is present:

– The albumin/creatinine ratio (ACR) is 2.5g/gm or more (nephrotic range
proteinuria)

– There is hypertension that qualifies for at least a 10% rating under
code 7101

A 0% rating is given if the GFR is 60 mL/min or
more AND at least one of

the following is present:

– The albumin/creatinine ratio (ACR) is between 0.03 and 2.49 g/gm

– There is hypertension that only qualifies for a 0% rating under code
7101

Note: Both
estimated GFR (eGFR) and creatinine based approximations of GFR will be
accepted for GFR ratings as long as they are calculated by a qualified
physician.

These are by far the biggest changes
proposed. The VA feels that the current renal ratings are based on out-dated
medical tests and other vague standards. The glomerular filtration rate is now the
medical standard used to measure how well kidneys are filtering the blood. As
it is a more accurate test of kidney health, the VA proposes to use it as the
standard for rating criteria.

The VA recognizes that the additional
rating criteria is necessary to ensure that the full picture of the disease is
taken into account for rating purposes. This is especially important for the
30% and 0% ratings, as a high GFR may not mean that the kidney isn’t impaired
and causing symptoms. Thus both hypertension and the ACR are taken into account
at these levels.

The 100% rating for individuals on the
kidney transplant list is another important addition. Do note, however, that
this is only for the time when they are waiting for the transplant. Once the
transplant occurs (and the rehab period is over), the rating will be based on
the functioning of the new kidney.

Code 7502 for nephritis remains the same,
except that the note stating that only nephritis or a heart disease caused by
the same condition (note both) could be rated is now extended to ALL renal
conditions. So…

NEW
NOTE FOR ALL RENAL CONDITIONS:

Renal disease is often closely related to heart disease. If renal disease is present and a
heart disease is present and both are caused by the same general condition,
then only one rating can be given even though there are two
organs affected by the condition. Only the condition that rates the highest is
used. The heart disease can, however, be rated separately if one kidney was
removed because of renal disease but the remaining kidney is healthy. Then the
heart disease warrants its own rating and the removed kidney can receive its
own rating under code 7500. The heart disease could also be rated separately if the renal disease is severe enough to need regular
dialysis.

All renal conditions are often closely
related to heart conditions, so to limit this rule to just cases of nephritis
doesn’t make sense. If the heart condition is caused by the same thing as the
renal condition, then it applies.

-Current- Code 7533: Any cystic disease
of the kidney is rated under this code. A cyst is a
sac most often containing fluid that can grow anywhere in the body. Many do not
cause problems, but some can seriously affect the functioning of the organs.

-Proposed- Code 7533: Any cystic disease of the kidney is
rated under this code. A cyst is a sac most often containing fluid that
can grow anywhere in the body. Many do not cause problems, but some can
seriously affect the functioning of the organs. Some conditions rated under
this code include poycystic diseases,
uremic medullary cystic disease, medullary sponge kidney, hereditary nephritis,
Alport’s syndrome, cystinosis, primary oxalosis, Fabry’s disease, and more.

Again, the VA is just
adding more conditions to this code to make sure that they are rated under the
most appropriate code.

-Current- Code 7534: Atherosclerotic
renal disease (also known as renal artery stenosis or atheroembolic renal disease) is a condition where the artery
to the kidney narrows and decreases the blood flow to the kidney.

-Proposed- Code 7534: Atherosclerotic renal disease (also
known as renal artery stenosis, atheroembolic renal disease, or large vessel disease) is a
condition where the artery to the kidney narrows and decreases the blood flow
to the kidney.

Similarly, the VA just wants to make sure
that large vessel disease is properly rated under this code.

-Current- Code 7537: Interstitial
nephritis occurs when the spaces between the
tubules in the kidney swell. This reduces the ability of the kidneys to filter
blood.

-Proposed- Code 7537: Interstitial nephritis occurs
when the spaces between the tubules in the kidney swell. This reduces the
ability of the kidneys to filter blood. This code also covers gouty nephropathy (the decrease of
kidney function caused by high levels of uric acid due to gout) and disorders of calcium metabolism (the
inability to properly metabolize calcium).

The VA feels that code 7537 is the best
rating option for gouty nephropathy and disorders of calcium metabolism and so
adds them here.

-Current- Code 7539: Renal amyloid
disease is caused by the buildup of protein in the
kidney, which may result in the kidney not being able to filter blood.

-Current- Code 7541: Renal Involvement in
other conditions. So, if the kidneys are affected by
conditions like sickle cell anemia, lupus, or diabetes, it can be rated
separately from those conditions.

-Proposed- Code 7539: Renal amyloid disease is
caused by the buildup of protein in the kidney, which may result in the
kidney not being able to filter blood.

In addition, renal involvement in
other systemic conditions is rated under this code. This includes renal
involvement in conditions such as lupus, sickle cell anemia, vasculitis,
Henoch-Schonlein syndrome, and other systemic conditions.

-Proposed- Code 7541: Renal involvement in
diabetes mellitus is rated under this code. So if a veteran is diagnosed with
either type I or type II diabetes, and it causes a decrease in renal function,
it would be rated under this code.

For these two codes,
the VA basically combined them all under code 7539. They only left diabetes
mellitus separate because they wanted to be able to more accurately track the
rate of this condition in the veteran population. Thus code 7541 is now just
for renal involvement in diabetes.

-NEW Proposed Code-Code 7544:Renal disease
caused by viral infections, such as HIV and Hepatitis B or C, are rated
under this code. This code includes renal disease caused by the treatment of
such viral infections as well.

The VA proposes to add
a new code to specifically cover diseases caused by viral infections. While
this code is not limited to HIV and Hepatitis B or C, for other viral
infections to qualify, there must be regular clinical proof that the infection
itself or its treatment causes kidney disease. For this reason, Hepatitis A is
not included as there is clinical proof that it does not cause kidney disease.

-Current- Code 7508: Nephrolithiasis (also
known as kidney stones) is the presence of stones in the kidney or
ureter. These stones block the flow of urine through the tubes. This condition
is rated as hydronephrosis unless stones are repeatedly formed and it
requires either drug therapy, diet therapy, or removal surgeries or procedures
3 or more times each year. If this is the case, it is rated 30%. Otherwise,
rate as hydronephrosis.

-Current- Code 7510: Ureterolithiasis is
the presence of stones in the ureter. These stones can block the flow of urine
through the tubes. This condition is rated as hydronephrosis unless stones are repeatedly
formed and it requires either drug therapy, diet therapy, or removal
surgeries or procedures 3 or more times each year. If this is the case, it is
rated 30%. Otherwise, rate as hydronephrosis.

-Proposed- Code 7508: Nephrolithiasis (also known as kidney
stones) is the presence of stones in the kidney. Ureterolithiasis is the presence of stones in the ureter. Nephrocalcinosis is the buildup of
calcium in the kidneys that can lead to stone formation. These stones block the
flow of urine through the tubes.

If stones are repeatedly formed and it requires removal surgeries
or procedures 3 or more times each year, it is rated 30%. Otherwise, rate as
hydronephrosis.

The VA proposes
combining codes 7508 and 7510 into a single code since both deal with the formation
of stones that block the urinary tract. They also suggest adding
nephrocalcinosis to this code to ensure its proper rating. The ratings for this
would mostly stay the same, but dietary and drug treatments for stones have not
proven pertinent to this condition, so they suggest removing them.

-Current- Code 7520: If half or more of the penis
is removed, then it is rated 30%. This condition can also be rated under
the urinary rating system if that can result in a higher rating than 30%.

-Current- Code 7521: If the glans is removed, it
is rated 20%. This condition can also be rated under the urinary rating system
if that can result in a higher rating than 20%.

-Proposed- Code 7520: If half or more of the penis is removed,
then it is rated 30%. This condition may qualify for SMC-K as loss of use of a
creative organ.

-Proposed- Code 7521: If the glans is removed, it is rated 20%. This
condition may qualify for SMC-K as loss of use of a creative organ.

The VA proposes to remove the option to rate
these conditions as urinary dysfunction since most of the circumstances around
urinary dysfunction (like leakage, use of a pad, etc.) don’t really apply.
These both, however, might qualify for Special Monthly Compensation, Category K
(SMC-K) since they may result in the loss of use of the creative organ, if it
no longer can function in that way.

-Current- Code 7522: If the penis is
deformed and cannot erect, then it is rated 20%.

-Proposed- Code 7522: Erectile dysfunction, for any reason, is
rated 0%. This condition may qualify for SMC-K as loss of use of a creative
organ.

This is the change that is going to cause
the most waves. The VA proposes to no longer rate erectile dysfunction at all.
They justify this change by claiming that they offer compensable ratings for
conditions that interfere with the veteran’s ability to work. Erectile
dysfunction does not interfere with the veteran’s ability to work, and so
should not be rated more than 0%.

They also add a note stating that
Peyronie’s Disease is not a ratable condition and cannot be rated under code
7522.

This condition may, however, still qualify
for Special Monthly Compensation,
Category K (SMC-K) since it is considered loss of use of a reproductive organ.

-NEW Proposed Code-Code 7543:Varicocele (enlarged veins in the
scrotum) and hydrocele (the build-up
of fluid around the testicles) are both rated 0% under this code. These conditions may qualify for SMC-K as loss
of use of a creative organ if they result in infertility.

The VA proposes adding a new code to cover varicocele and
hydrocele—both conditions that are not currently addressed in the VASRD. These
conditions do not interfere with the ability of the veteran to work, and so the
VA proposes only a 0% rating. However, if they lead to infertility, they would
qualify for SMC-K.

Varicocele and Hydrocele to both testis have been identified since arriving to VA Hines, but also the PAIN which spreads to the groin and lower abdomen area making it hard to walk/sit. And they recently found a lump/mass in the right spermatic cord with a continuation of blood in the semen (spermatozoa) as well as occasionally in the urine after years of monitoring the lump/mass on the right testicle.

How would that even be looked at as a rating???It's pyramided already isn't it???

The VA will only give one rating for the overall condition of the testicles/scrotum. Although it is technically for "atrophy" of the testicles, code 7523 is usually used for any condition that causes the testicles to not function properly. 20% is given under this code if both testicles no longer function. Additional compensation can be given under SMC-K for infertility.

These conditions all have to be definitely considered service-connected in order to qualify. Did they say that you infertility was not service-connected in their rating decision? Even though it was noted on the exam, the condom use should not have played a part in the rating at all. If you were diagnosed as infertile more than a year after separation from service, it could be very difficult to prove service-connection.

Everything from what I listed was verified after service and The GU Clinic has been following-up since leaving service in Nov 2000, except the sterility.I asked about it persistently since 2001, (side note Sleep Apnea also) but they (GU Clinic) kept saying it was not necessary and that all of this was normal for males my age.

And to give you an idea of how this went. 10 years later of not giving me a diagnosis as to what was going on and how to fix it Patient Advocate intervened and then I was sent to the Fertility Center and whola.... Another additional issue. Sterile.

Leaving me with more questions, like If you know I left service with Varico/Hydroce/Spermatoza/pain in testis-glans/Hematuria/enlarged prostate w/pain No STD from service exams and every VA Exam you would think a sterility exam would have been one of the first or second tests to do when I was now being treated at Hines VA.

I was rated 0% for all that lumped together as an initial rating for leaving service.

On a side note the Sleep Apnea exam was scheduled by consult within a year. But the actual study did not occur until Sep 2004. Failed it. CPAP Issued 2006. CLAIM totally denied. Go Figure!!!

They said the infertility could not be identified as in-service since I always used protection and did not father any children while active duty. Well DUH... Here's some Motrin and 7Day treatment just in case. Again and Again.. every time it would get bad and painful.

The lump/nodule found 2015 in the right spermatic cord, could it be the cause of the epididymo-orchitis?

If I remember my nuts are fluctuating in size but the left is always smaller than the right and I would have to look for the Ultrasound numbers but htere is like 2 cm difference from what I remember the Technician said after the 3rd Exam and it bounces back and forth dependent on each axis???? w/swelling.. or something.

I am unable to diagnose you with so little information and not being your physician, but epididymo-orchitis is inflammation usually caused by infection that can easily be cleared up by treatment. You'll need to talk to your doctor about an official diagnosis for the inflammation.

JP4 jet fuel was inadvertently pumped into fresh water tanks while I was at sea for 9 months, I drank it, ate food cooked in it, cloths and bedding were washed in it and I showered in it. I got throat cancer twice and got a total of 13 weeks of chemo and radiation. How can I get compensated for loss of salivary glands and retinal vein occlusion from 45 day coughing fit because of aspiration of food into lung?

You can apply for conditions caused by exposure to the fuel by submitting evidence of the exposure (amounts, length of time, etc.) and any evidence you can find that such exposure is known to cause your conditions. If the VA feels your evidence is strong enough, they will grant your claim.

I have a VA rated service connected lumbar spine injury that has needed several spine surgeries. During the last one, my nervous system was damaged causing retrograde ejaculation. It seems like this is not rateable. Is this correct?

What is the definition of infertility? I should still have viable sperm, all of the sperm simply travels to the bladder and not out of the urethra because of my complete retrograde ejaculation. Second, the urologist who diagnosed me did so from my verbal description of that one symptom and the fact that I had just had lumbar surgery with complications. If I am considered infertal since I can no longer have children without medical interventions for both me and my partner, how do I prove I actually have r. e? Finally, I was told that the nerve that was damaged was part of my autonomic nervous system and that that system can’t be tested. Additionally, all of the va codes for autonomic damage were for diseases that did not seem to apply. My hearing was damaged and I have a 10% rating, but I still have hearing. My ability to have children has been severely affected, perhaps erased as a consequence of my service. Is there really no va rating for me?

The doctor should have fully examined and recorded your condition. Check the medical records. If it was not recorded completely, then you can go back and have them do a more thorough exam.

As long as you have medical records that show the diagnosis and treatment of your conditions, you should be able to apply for them. The VA, however, only rates conditions that limit your ability to do your job and earn a supportive income. Conditions like retrograde ejaculation do not directly interfere with your ability to work and so are not given as high of ratings as something like hearing loss.

Pain is not currently included in the ratings unless specifically noted. The VA has not yet released whether or not the court decision stating pain as an independent disability will yet be reflected in the ratings.

I’m a Vietnam Vet that was just given a 20% rating under 7522 for Peyronie’s disease. It was under ED as a secondary to residuals of prostate cancer radical prostatectomy. Is there any chance this rating will be grandfathered in if they change the rules for Peyronie’s disease?

Unfortunatey, unlikey. They are directly choosing to eliminate any ratings for Peyronie's disease, so it is likely that you will lose your rating.

However, they have not yet published the final rulings, and those rulings will have guidelines on how they are to be applied. They may say to only apply them to new conditions being rated after the effective date and so may not effect past ratings at all.